Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

EMS Garage Special Edition: How to Improve Survival from Sudden Cardiac Arrest Episode 48

Also posted over at Paramedicine 101. Go check out the rest of what is there.

I occasionally appear on EMS Garage. I had to work and missed this episode.[1] I guess that a lot of people will be glad. Just listening to the first few minutes got me started on this post.

First, Mickey S. Eisenberg, MD is the special guest. He has just written a book called Resuscitate!: How Your Community Can Improve Survival from Sudden Cardiac Arrest.[2] He is an excellent person to talk with about this topic. He is one of the people everyone recognizes as an expert. Certainly, I cannot disagree with him, but I do.

Greg Friese is explaining about one of the ideas from the book. That cardiac arrest survival is the best way to determine the quality of a system. I agree that cardiac arrest survival is important, but since cardiac arrest has only been shown to be improved by BLS treatments (compressions and rapid defibrillation – both of which used to be physician-only treatments), it is a mistake to think that this tells you a lot about the quality of an ALS system.

ALS has been shown to worsen the outcome of cardiac arrest, by interfering with good chest compressions, but no ALS treatment has been shown to improve outcome from cardiac arrest. I might even turn that around and say that cardiac arrest outcome may be improved by no ALS.

This may not be entirely true,[3] but it is not unreasonable. There is evidence to show that rapid ALS leads to worse outcomes.[4] There is also evidence to show that ALS leads to worse outcomes.[5]

I do not see evidence that ALS is important in resuscitation. Therefore, how can cardiac resuscitation be an effective measure of the effectiveness of an ALS service?

Cardiac arrest represents about one percent of the EMS calls in any given community, but the management of this one percent encapsulates everything good and bad about a communities EMS system.[6]

In discussing this, Jamie Davis (I think) comments that resuscitation rates are the easiest metric to quantify. I agree that this is easy to quantify. Being easy to quantify and being important do not necessarily go together. The story of the drunk searching for his keys under the streetlight is relevant. He lost his keys elsewhere, but he is looking where the light is better. It will not improve his ability to find his keys, but he will feel better while he is looking. We should not be imitating a drunk, who cannot find his keys. For all we know, they could still be in his pocket, or the bartender might have taken them.

Now that I got that rant out, the rest of the show was excellent. Everybody asked good questions. A lot was covered. The only complaint I have about the rest of the show is that it was too short. There is so much to cover that much, much more than an hour needs to be devoted to this. If I had been involved, the show might have gotten bogged down on the topic I just covered, and never covered some of the much more interesting material that they did cover.

I will write several posts about the many wonderful, positive points in the show.


^ 1 EMS Garage Special Edition: How to Improve Survival from Sudden Cardiac Arrest Episode 48
EMS Garage
Links to broadcast and downloads

^ 2 Resuscitate!: How Your Community Can Improve Survival from Sudden Cardiac Arrest
By Mickey S. Eisenberg, MD
Amazon.com link with a good video review by Greg Friese.

^ 3 Impact of advanced cardiac life support-skilled paramedics on survival from out-of-hospital cardiac arrest in a statewide emergency medical service.
Woodall J, McCarthy M, Johnston T, Tippett V, Bonham R.
Emerg Med J. 2007 Feb;24(2):134-8.
PMID: 17251628 [PubMed – indexed for MEDLINE]

Conclusions: Highly trained ACLS-skilled paramedics provide added survival benefit in EMS systems not optimised for early defibrillation. The reasons for this benefit are multifactorial, but may be the result of greater skill level and more informed use of the full range of prehospital interventions.

My highlighting, but that may be all that is necessary to explain the benefit. The big question is, Where are the studies showing a benefit from prehospital ALS in cardiac arrest? We can theorize endlessly about potential benefits, but where is the evidence of benefit. It is silly to theorize about the reason for a benefit, when we do not even have evidence that the benefit exists.

Maybe we should be optimizing these systems for early defibrillation or look at systems that have already done this.

^ 4 Cardiac Arrest Survival Rates Depend on Paramedic Experience
Michael R Sayre, Al Hallstrom, Thomas D Rea, Lois Van Ottingham, Lynn J White, James Christenson, Vince N Mosesso, Andy R Anton, Michele Olsufka, Sarah Pennington, Stephen Yahn, James Husar, Leonard A Cobb.
Academic Emergency Medicine; Volume 13 Issue s5; May 2006; pages S55 – S56; abstract number 121
The abstract is available here.

^ 5 Interruptions in Cardiopulmonary Resuscitation From Paramedic Endotracheal Intubation
Henry E. Wang, MD, MS
Scott J. Simeone, BS, NREMT-P
Matthew D. Weaver, BS, NREMT-P
Clifton W. Callaway, MD, PhD
Presented at the Society for Academic Emergency Medicine annual meeting, May 2008, Washington, DC.
Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA
The abstract is available here.

^ 6 Resuscitate!: How Your Community Can Improve Survival from Sudden Cardiac Arrest
The Big Picture
Page 18.
Same as footnote [2].


Zero Tolerance I – Basic EMT Oversight of Paramedics

Imagine a world where an organization that is not really interested in providing EMS has been put in charge of EMS. How would patient care concerns be handled in an organization that having engaged in a hostile takeover of the local ambulance drivers, finds it is now responsible for supervising patient care. Not that this would ever happen, because the public is too sensible to fall for this.

This would be like Walmart taking over hospitals in the area, because they already have much of what a hospital uses and they have an excellent supply network to get everything else (and at a lower price). But this is EMS, so if your branch of government is faced with downsizing, you might as well take over the unimportant but staffing friendly job that is EMS. What could go wrong?

Well, how would we arrange supervision, so that the best care is delivered to the patient? It is a patient care business, so the existing medical personnel, in the organization taking over, would handle that. That is if there were any medical personnel in the corporate raider’s non-medical supervisory structure. Here is a story from just such a corporate raider situation. Of course, this is not a real story, because no corporate raider would ever have the hubris to do this.

Imagine 2 different protocol violations. The protocol is below.[1] How would you handle the discipline on these two instances of protocol violation?

One violation is by a medic giving morphine for back pain without medical command permission. The protocol has no provision for treating back pain without at least attempting medical command contact. MVC (Motor Vehicle Collision) with a chronic pain patient already receiving pain medication. Medic does not call for orders. Medic gives everyone at the ED a bunch of attitude. Medic is suspended.

The second violation is by a different medic. A patient with an obvious humerus fracture. Pain is 10/10. If you look at the protocol, they do not allow treatment if the GCS (Glasgow Coma Score) is less than 15. I do not believe that you can have true 10/10 pain and be fully oriented, but that is a different post. The medic initiates treatment with 5 mg morphine slow IVP (IntraVenous Push). The protocol states that dosing is to be 2 mg to 4 mg at a time. The pain is still 10/10. The medic repeats the dose of 5 mg morphine slow IVP. Pain is now 7/10. Atta boy!

This is what EMS is about. We are supposed to make a difference. This is good treatment. This treatment did slightly exceed the dosing guidelines in the protocol. I have started out with 10 mg morphine on several patients – slow IVP initial dose. I have repeated the dose of 10 mg morphine later in the same patients. This is not bad care. We are supposed to adjust treatment to the patient.

The second medic arrives at the ED (Emergency Department) with the much improved patient, realizes that the protocol called for 4 mg, 4 mg, and 2 mg as the acceptable way of treating the patient. Perhaps 3 1/3 mg, 3 1/3 mg, and 3 1/3 mg. The medic notifies the doctor. The doctor, recognizes that the protocol violation is not a significant one and begins treating the patient’s 7/10 pain with dilaudid, which is much stronger than morphine.

In the first case, the medic gave the doctor a hard time about the medic’s violation of protocol.

In the second case, the medic started out by pointing out the protocol violation. Not a willful violation, just a mistake of dosing when dealing with a patient in severe pain. Not even close to an unreasonable dose of morphine, so there is no significant danger to the patient.

The second medic notified all of the appropriate people in the NEMSO (short for – NEMSOTCPEMSBOAAA, which is short for – Non-EMS Organization That Coincidentally Provides EMS, But Only As An Afterthought) and writes an incident report. The brass feel that informal counseling is all that is needed. The Executive Grand Supervising IHMITTDTDWABOM (I Have More Important Things To Do Than Deal With A Bunch Of Medics) looks at the paperwork and decides that there is no difference between these protocol violations. The Executive Grand Supervising IHMITTDTDWABOM decides that the punishment should be the same as for the completely outside of protocol treatment.

The Supervising IHMITTDTDWABOM, Grand Supervising IHMITTDTDWABOM and Medical Director all disagree with the Executive Grand Supervising IHMITTDTDWABOM. They make it clear that they disagree. They are overruled. Now this Executive Grand Supervising IHMITTDTDWABOM is not a Paramedic, not a Nurse, not a Physician Assistant, and not a Doctor. There are so many things that this Executive Grand Supervising IHMITTDTDWABOM is not, that I could go on for days. That does not stop him from overruling the medical director on patient care issues.

What describes dangerous better? Some novice completely untrained person telling experts that he knows better. Does he offer proof to support his contrary to medical advice decision? No.

He knows better than everyone trained in the field, because that is the way the chain of command works. If that know-it-all Medical Director doesn’t keep his nose out of corporate raider business, the Medical Director can find work elsewhere. After all, Medical Directors are a dime a dozen.

Are these protocol violations the same?

Both are cases of medical treatment of pain with morphine.

Let us assume that the Executive Grand Supervising IHMITTDTDWABOM responds to a magnesium fire. You know those retina burning, hard to recognize fires. If the Executive Grand Supervising IHMITTDTDWABOM decides it is a fire and should be treated just like any other fire, that would be bad. If the Executive Grand Supervising IHMITTDTDWABOM does not see the difference between these fires, he is applying the same lack of understanding that he is applying in making medical decisions. Not that this has anything to do with Fire Departments as corporate raiders. That would be silly.

The discipline that seems most needed here is suspension, at the least. Not suspension for the medic, but suspension for the Executive Grand Supervising IHMITTDTDWABOM making ALS (Advanced Life Support) medical decisions without any training or understanding of his complete inability to be competent in this are.

Performance Indicators:

Pain Scale Before and After Treatment?

Great Job!

Vital Signs Before and After Treatment?

Great Job!

Patient Mental Status?

Great Job!

Response to Treatment?

Great Job!

Patient Disposition?

Great Job!

This is performance that should be punished?

Anyway, here is the protocol. Please let me know what you think in the comments.

^ 1 Pain Management:

Examples Include:
Suspected kidney stones
Sickle cell crisis
Isolated extremity trauma

Initial treatment is according to relevant protocol

Pain >5 on a 0 to 10 scale?

Blood pressure > 100 mmHg systolic with no evidence of inadequate perfusion?

Glasgow Coma Score = 15?

Isolated extremity trauma?

2-4 mg Morphine IV/IM every 5 minutes (Do not give more than 10 mg without medical command permission)

Contact Medical Command

Pediatric Patients (<5 years old):
Morphine 0.1 mg/kg IV/IM (May repeat one time only)
(Do not give more than the adult dose without medical command permission)

Performance Indicators:

Pain Scale Before and After Treatment
Vital Signs Before and After Treatment
Patient Mental Status
Response to Treatment
Patient Disposition